What should be included in a doctor’s bag?

GPs have always carried some equipment and drugs with them when they visit patients. This overview considers what a ‘doctor’s bag’ actually is, and discusses the items it might need to contain for GP home visits as well as the factors to consider when stocking it.

In the interests of good clinical practice, it is expected that most GPs will carry a doctor’s bag stocked with equipment and drugs for medical situations outside the surgery (on home visits, for example). Perhaps surprisingly, though, there are no specific regulations as to the items the bag should contain. Good practice guidelines from RCGP1 suggest that “the exemplary GP has up-to-date emergency equipment and drugs, and ensures that they are available for any doctor, eg locum, working in the practice.” On the other hand, the same guidelines note: “The unacceptable GP has insufficient emergency drugs or equipment, or has drugs that are out of date.”

The onus, then, is very much about each individual practice curating an assortment of drugs and equipment that works best for their own specific practice needs. The ‘bag’ can vary from a stock of medicine and/or equipment carried individually by each GP, to a designated emergency store of drugs that is available in the surgery and that may be quite different in the specifics of its contents and how it is managed.

This overview outlines what drugs and equipment might be taken by GPs on home visits; it does not deal with drugs stocked for use in routine clinical practice within the surgery or by out-of-hours primary care services, for which separate guidance and advice applies.

Location, location

One of the key factors in deciding how to stock the doctor’s bag is where the surgery in question is located. For example, a GP working in a remote rural area that is not very close to a major hospital and is a distance from reliable ambulance paramedic cover may need a more comprehensive stock of emergency drugs than one working in a city with these resources close by. Similarly, availability of out-of-hours controlled drugs and services and a 24-hour pharmacy will strongly influence what the GP carries.

What might be carried in a doctor’s bag is also determined by the medical conditions likely to be encountered in the community that the surgery serves, the medicines the GP is confident in using, and the storage requirements, shelf-life and costs of such drugs.

Dr Louise Newson, a West Midlands-based GP who also contributes to the website Patient (patient.info), says: “I work one day a week in a suburban practice, so for me to be carrying drugs around doesn’t make sense as they would get out of date. I’m also usually really close to the practice so could nip back and get anything that was needed.

“If I were in the Outer Hebrides, my bag would be very different as I’d no doubt be carrying an adrenaline pen, oxygen and probably a nebuliser, but in my situation it’s the simplest items I find most useful – like hand sanitiser, for where I wouldn’t want to wash my hands in a patient’s bathroom, and a urine sample bottle to leave behind, as invariably the patient won’t produce a sample while I’m there. Over the last decade, I’ve found carrying a pulse oximeter (to measure a patient’s blood oxygen saturation) more and more useful, though, because this can really help to assess patients. If they need oxygen quickly, they clearly need 999 or to go into hospital.”

Indeed, GPs are increasingly less likely to carry a range of medicines for acute or emergency situations, and acute services and ambulance trusts in some areas may actually discourage GPs from attending emergencies as it could delay patient transfers.

However, there is still a need for some GPs to carry a range of medicines for use in acute situations when on home visits, and in 2015 the Drug and Therapeutics Bulletin published ‘Drugs for the doctor’s bag: 1–adults’2 and ‘Drugs for the doctor’s bag: 2–children’,3 updating identically named papers from 2005. These suggest current medicines suitable for GPs to carry with them for emergency or acute treatment.

Table 1 provides a summary of suitable drugs that could be included in a GP’s bag for the treatment of adult patients.

Upkeep and audit

Because medication in doctor’s bags is out of sight, it can become forgotten about so a process and system should be in place to check that medications are in date and equipment is well maintained. For example, if GPs are taking equipment, such as an electronic blood pressure monitor, out with them on patient visits, they must remember that it requires portable appliance testing and must be given up for testing when required. As well as potentially impacting on patient safety, slipshod auditing in this area could affect the rating of a practice, as the doctor’s bag and how it is managed is a valid area that may be examined during Care Quality Commission inspections.

As well as a system being in place to ensure regular (ideally at least twice a year) reviewing of usage and expiry dates, the original batch numbers and expiry dates of all the doctor’s bag drugs should be recorded when administered, and details of any medications administered should be entered into the patient’s record as soon as practicable.

If a doctor needs to carry controlled drugs (CDs), the rules are even more stringent. A CD register, separate from the practice register, is needed for all stock held within that bag, and each doctor must be responsible for the receipt and supply of CDs from their own bag. Restocking a bag with CDs for home visits from practice stock should be witnessed by another member of the practice staff, as should the appropriate entries into the practice’s CD register. Where a prescription is written by a doctor following the administration of a CD to a patient, the doctor should endorse the prescription form with the word “administered” and the date and information should also be entered into the patient’s record as soon as possible. Schedule 2 CDs (including morphine and pethidine) returned from patient stock or expired should be destroyed in the presence of an authorised healthcare professional and a record of the destruction made in a separate book set aside for this purpose.

If managing all this gets rather too complicated, there is online software (www.doctorsbaguk.com) that can help, endorsed by the RCGP and cited as “useful” by the Oxford Handbook of General Practice. Created and run by Dr Mark Street, it is a web-based solution that GPs and other authorised healthcare workers within the practice can use to log and manage all drugs, vaccines and equipment within the doctor’s bag, or in surgery stocks and fridges. When the GP gives a drug or CD to a patient, they enter the details onto the system, which then automatically adjusts the stock level. With the appropriate permissions, the system can also automatically re-order drugs when stocks fall below a minimum level.

An NHS GP himself for 21 years, Dr Street says he set up the software in 2008 “after many years of on-call and home visits and realising that our practice had no system in place to check the expiry dates of drugs.” He adds that many members throughout the UK and overseas say they have joined the site due to similar near misses with expired drugs.

There is also the time-saving aspect that an online system such as www.doctorsbaguk.com can provide compared with laborious paper reminders and checks, something that Birmingham-based GP, Dr Bhinder Jheeta, also an undergraduate tutor and GP appraiser, appreciates. “I find it an absolutely brilliant tool that saves so many hours of GP administration time,” he remarks. “It’s also actually quite enjoyable doing the entries, plus there are no more worries over when my adrenaline injection expires or runs out of stock.”

What type of bag?

With the contents selected and managed, there is also the question of the physical bag itself and what attributes it should have in order to transport medicines around safely. While there are no actual rules, good practice guidelines summarised in a PatientPlus article4 dictate that:
• It must be lockable and not left unattended, and stored, when not in use, in a cool place in the surgery or at home rather than in the doctor’s car.
• When it is in the car, the bag should be locked out of sight in the vehicle boot.
• A silver-coloured or cool bag rather than a traditional black bag should be considered, as most medicines should be stored between 4°C and 25°C. A maximum-minimum thermometer in the bag could be useful, to record extremes of temperature.
• The bag should be kept closed when not in use, as bright lights may inactivate some drugs, eg injectable prochlorperazine.

However, as has already been discussed, flexibility and appropriateness to purpose are key with any GP’s bag. As long as solid accountability and safety measures are in place, GPs can follow any reasonable approach, which may include choosing to disguise the fact they are carrying any medical supplies at all. Depending on individual circumstances (and if nothing hazardous is being carried), this could simply be achieved by wearing a coat with capacious pockets.

Carrying a bag that does not obviously look like a medical bag is also common. “I just use an ordinary looking, largish briefcase that’s wipe clean and practical,” says Dr Newson. “I worked in Manchester previously and visiting run-down areas where there were drug abusers could make you feel very vulnerable. In these situations, I didn’t want people to know I was a doctor – you really don’t want a medical-looking bag as you’re an easy target.” Similarly, while in theory it may be good practice to display the correct ‘Hazchem’ sticker in a doctor’s car when oxygen is carried, some doctors may feel this compromises security and so this can be a personal choice dependent on the environment and level of risk.

While GPs will always aim to be equipped and able to deal with medical problems outside the surgery, the archetypal battered leather bag that used to mark out the doctor on call may no longer be so relevant to 21st century primary care.

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